Gout and low carb

GoutIt’s occasionally claimed that low-carb or keto diets high in meat often cause gout. This does not appear to be true (nor does a low-carb diet have to be high in meat).

However, there may possibly be a temporary increase in risk of gout during the first six weeks on a strict low-carb diet. After this initial time period, a low-carb diet is likely neutral, or even protective, when it comes to gout.

Keep reading to find out what gout is and how to avoid it.

What gout is

Gout is a sudden and painful inflammation of a joint, most often at the base of the big toe (see image). It may also affect other joints, like heels, knees, wrists and finger joints.

The cause of gout is elevated levels of uric acid in the blood, resulting in crystals depositing in the affected joint.

Gout is more common in people who are overweight and have metabolic syndrome, and have thus become more common in recent decades, affecting about 6% of adult men and 2% of women (it’s even more common in older people).1 Historically, it was known as “the disease of kings” or a “rich man’s disease”, but now everyone can afford… sugar.

Meat and gout

Gout has often been blamed on excessive consumption of meat. This is because the uric acid that causes gout is a breakdown product of purines, a building block of protein, that is highly concentrated in meat.

However, avoiding meat seems to have little effect on the risk of gout, and even vegetarians get gout much more often than would be expected if this was the main cause.

Eating more protein (like meat) seems to increase the excretion of uric acid from the kidneys, through the urine, thus not having much of an effect on the blood uric acid levels… or the risk of gout.

Sugar and gout

As there is a very strong connection between gout, obesity, type 2 diabetes and metabolic syndrome, it’s possible that they are all primarily caused by the same thing: sugar and other refined carbohydrates.

In fact, high blood levels of insulin – a consequence of a diet high in refined carbs – has been shown to increase uric acid levels, probably by decreasing the excretion of uric acid by the kidneys.

There is a striking history of gout suddenly becoming common in populations just as sugar consumption started to rise sharply (e.g. in Britain during the eighteenth century, paralleling the birth of the country’s sugar industry).

There’s also experimental proof, showing that consuming fructose (a main component of sugar) sharply increases levels of uric acid in the body.

Alcohol and fructose are metabolized in similar ways in the body, and alcohol increases uric acid levels in the same way as fructose.

Low carb, uric acid and gout

Short term studies show a temporary rise in uric acid during the first few weeks when starting a strict (i.e. keto) low-carb diet. This effect seems to disappear after about six weeks, with uric acid returning to baseline or even lower.

Studies show no significant change in uric acid levels in people doing a low-carb diet over several months or years.2 The exception is one study that actually showed uric acid going down significantly after 6 months on low carb, suggesting it may decrease the risk of gout.3  
After dozens of high-quality studies comparing low-carb diets to other diets, there seems to be none noticing any obvious difference in the risk of gout, although no study has focussed on this specific question in detail.

Doctors regularly treating patients with low-carb diets apparently do not notice an increase in gout episodes even during the first time period. So if there exists an increase in risk during the first few weeks it is likely small or moderate.

Long-term uric acid levels tend to become low on low carb, along with other markers of metabolic syndrome4 and even patients that used to suffer from gout can potentially become gout free. However, it might take months or even years to completely reverse their insulin resistance and achieve normal levels.

 

 

How to avoid gout

Here’s how to avoid gout long term, using only lifestyle modifications:

  1. Minimize intake of sugar.5
  2. Reduce intake of alcohol. Particularly avoid beer and other high-carb alcoholic drinks.6
  3. Lose excess weight and reverse metabolic syndrome. Low carb is a good treatment, as is intermittent fasting.7

As a bonus, these lifestyle modifications have many other positive effects on weight and health. However, if they are not enough, the drug allopurinol is highly effective in preventing gout.8

Given that there may be a temporary rise in uric acid during the first few weeks on a strict low carb diet, people who’ve previously had troublesome gout attacks may want to consider using the drug allopurinol while starting low carb, starting taking the drug at least a week in advance, to minimize any risk of a new gout attack.

 
 

Meat or no meat?

Avoiding meat should not be necessary or effective when it comes to gout prevention.

Furthermore, please note that a low-carb diet is not supposed to be especially high protein or high meat anyway. An effective low-carb diet should be moderate in protein and instead high in natural fat.

A well-formulated low-carb diet (i.e. a low-carb, high-fat diet) likely reduces the risk of gout long term.

Do you have anything to add?

Do you have anything to add to this guide? Have you experienced any change in gout problems on low carb? Are you aware of further studies regarding gout and low carb?

Feel free to leave a comment below, we’ll read them all.

More about gout

Gout and ketosis sometimes get mentioned in the media. Here’s an example from 2019:

Can we blame gout’s resurgence on ketosis?

Here’s an entire chapter about gout, from the award-winning science journalist and low-carb expert Gary Taubes:

Tim Ferriss: Gout: The Missing Chapter from Good Calories, Bad Calories

 
 

More low-carb side effects & how to cure them

Common early issues

Less common issues

 

Low-carb myths

 

More

Improve this page

Do you have any suggestion – big or small – to improve this page?
Anything that you’d like added or changed? Any other problems you’d like to see addressed?

Comment below or e-mail me at andreas@dietdoctor.com.

  1. Arthritis & Rheumatology 2011: Prevalence of gout and hyperuricemia in the US general population: The National Health and Nutrition Examination Survey 2007–2008

  2. NEJM 2003: A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obesity

    Obesity reviews 2012: Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors

  3. American Collage of Rheumatology 2014: High-Protein Diet (Atkins Diet) and Uric Acid Response

  4. E.g. triglycerides, liver enzymes, blood pressure, glucose, abdominal circumference, and weight.

  5. Sugar is worse than other carbohydrates, even refined carbs, because of the high concentration of uric acid-raising fructose.

  6. Beer not only contains alcohol, but also rapidly digestible carbs, raising insulin and thus lowering excretion of uric acid. Of less importance, beer also contains purines.

    If you want to drink alcohol, ideally choose options low in carbohydrates. This will still raise uric acid levels and the risk of gout, but not by as much:

    1. Low-carb alcohol
    2. Low-carb beer

  7. The American Journal of Medicine: Update on Importance of Diet in Gout

  8. Wikipedia: Allopurinol

1 2

64 comments

  1. Lacosta Hodges
    My husband has gout flare ups when he cheats. He has been lchf for 3 years. This year at the beach he had some refined sugar when we went out which triggered a gout flare up. I think it is his body's reaction to the spike in sugar. This just validates our commitment to the lchf lifestyle. If your body reacts that strongly to sugar when you are not used to it then its poison!
  2. Barbara
    I just cheated for several days while on vacation, came home, got back into ketosis and ended up with gout within a week. Never had it before. Terribly painful. Hobbled, couldn’t bear weight on my swollen red foot. I had been fat adapted for a long time previously and this certainly showed me how insulin resistant I truly am. I was uncomfortable taking the prescribed anti inflammatory and drank ACV and lemon juice instead, along w a pain med. Lesson learned. Hope I never experience this awful affliction again. My heart goes out to those who do.
  3. Arlene
    A few weeks I went much lower carb. I also increased my exercise levels considerably, and along with the heat (summer in Ontario, Canada can sometimes be brutal) ended up in ER with tachycardia.

    I take a 12.5mg thiazide diuretic for high blood pressure and this I believe was a factor as well in that I become quite dehydrated.

    Blood work indicated low potassium (3.2), low magnesium (.73mmol) and high uric acid (401 umol.)

    I had blood work done again to follow up on those results last week, and all this has resolved. My uric acid is down to 224 umol, and my potassium is normal at 4.5.

    For anyone taking diuretic medication for high blood pressure please be aware that there is a chance that this will additionally increase uric acid levels initially when significantly lowering carbohydrate intake and going into ketosis.

    In my case I am happy to report it was transitory and has resolved spontaneously.

  4. Linda
    About 3 years ago, I was on no particular diet, I had an episode of gout in my left big toe. When it didn't go away in a couple of weeks, my doctor gave me a prednisone shot. That did nothing. Then she prescribed allopurinol -- OMG - suddenly the gout became so much worse and spread to other joints including my left foot and ankle. I was unable to walk even to the bathroom and hubby had to push me in a wheelchair! I started researching and found that allopurinol should NOT be started during a gout outbreak. I called my pharmacist and he confirmed this was correct and to stop taking it immediately and call my doctor. She was very unconcerned! I hung up and determined to switch doctors right then and there. Further researching, I found an over-the-counter remedy on Amazon with a 90-day money back guarantee. I ordered it with 2-day shipping and started taking it. Literally in 3 days, my gout was so much better and in 6 days it was gone. I don't know if this will help anyone else, but the product is Urcinol. I'm just an ordinary customers (very satisfied customer) and have nothing to gain from putting this information out there. I would just be so happy if this helped others the way it has helped me. I recently had a blood test that showed my gout level was up a bit. I came home and checked the pills in my monthly pill case and found that I had inadvertently left it out when I filled it 2 weeks ago. I am convinced that it works for me and I hope it will help some of you. No one wants to deal with gout! I am on Week 2 of low carb and already down 5 lbs. and feeling so much more energetic and clear headed. Good luck everyone on your journey.
  5. JOHN
    normal keto does not brother my gout only after 3 continuous days of fasting brings it on. i just wonder if uric acid is stored in the fat cells that are getting burned? can not be in the food that i am eating because on a fast you do not eat anything. so where is the uric acid coming from? has to be in the fat cells. just my option, meat does not brother me, i ever eat liver a lot and it never hurts me, only fasting does
  6. Cyrus
    Interesting thread. I reduced my gout 90% when I fixed my gut health issues. There seems to be a relationship between gut bacteria and gout. Google "gut bacteria gout" to see the studies. Obviously, changing your diet and the foods you eat (protein, carbs, fat, fructose, etc.) will alter everyone's microbe different.

    My own healing moment came when I started taking GOS (Galactomune) which is a prebiotic that promotes the growth of bifidobacterium and lactobacillus. I believe GOS is technically a carb, but you don't have to take very much of it, or for very long. Food for thought for anyone struggling with this.

  7. Pekka Huttunen
    I have been on low carb diet now for five years. My gout episodes are basically non-existent. My arthritis doctor kept on telling me to avoid meat and fatty foods. I decided with advise from another doctor to do the opposite and also cut gluten off my diet. This decision basically saved my life!
  8. Brian
    I expect that liver function plays a predominant role in gout flare ups and often falls under the influence of various harsh inputs such as heavy carb loads, spikes in fructose, ketones etc. A livers function to cleanse out toxins, unic acids and ketones will be reduced if swamped by high carbs, fructose spikes, alchohol binges or large amounts of purines being converted.

    Non alchohol fatty liver disease diagnosis is a growing trend and likely a cause for my gout flare ups and triggered by generally flooding of it by rapid absorption spikes in fructose (including diet pop sweeteners that also wreak havoc), general over consumption of carbs and occasional binges of sweets or high purine meats.

    Don’t recommend anyone seek a single silver bullet solution to gout, such as tart cherries, but rather pursue the overall health of your liver to be the source of your blood level readings which are ultimately excreted by kidneys.

    The anti-inflammatory long term approach with herbs & meds as needed to boost should be paramount as well as avoiding of spike events to the liver.

    Staying well hydrated helps the body cleanse out toxins, uric acid crystals and ketones vs allowing them to settle in joints and causing inflammation.

  9. Burton Abrams
    While diet does affect the concentration of uric acid in the blood, it is not the principal factor. A much more important cause of excessive concentration of uric acid in the blood leading to gout is the reduction of oxygen in the body that occurs with sleep apnea, which is the frequent cessation of breathing for many seconds at a time during sleep. The intermittent reduced oxygen level in the blood causes all the cells to produce excess uric acid while it also reduces the solubility of uric uric acid in the blood, plus it gradually reduces kidney function so that removal of uric acid from the blood is slowed. The uric acid solution in the blood then becomes supersaturated, with the result that monosodium urate (MSU) crystals precipitate. When MSU forms in a joint, it activates an immune system response that causes the severe pain and inflammation of a gout attack.

    It is known that people with gout have increased risk for serious cardiac events and mortality, which are known consequences of sleep apnea. Increasing the dosage of the gout suppressing drugs allopurinol or febuxostat (Uloric) has been shown to have no beneficial effect on those risks. They are usually effective in suppressing gout attacks, but they do nothing to overcome the underlying sleep apnea.

    Sleep apnea has many known life-threatening consequences (eg, cardiovascular diseases, kidney disease, high blood pressure, diabetes, etc.) If it's left untreated for a long time, conditions leading to these consequences often become irreversible. But gout is an early warning of sleep apnea, allowing for its diagnosis and treatment before these irreversible conditions develop. It's ironic that gout sufferers are fortunate, in the sense that they have an early warning of the presence of sleep apnea. Overcoming the sleep apnea not only will prevent future gout attacks, but also will greatly reduce the risk for development of sleep apnea's serious consequences if treated early enough.

    Sleep apnea is readily treatable. The most important thing that a physician treating gout can do is send the patient for a sleep study, and prod the patient to follow the recommended treatment. The most important thing that a gout sufferer can do is insist on having a sleep study, and then follow the recommended treatment for it.

  10. Lyne Gagne
    I just saw my naturopathe and he told me cause he saw cristal in my urine and blood to reduce red meat, salt, cacao, and' sugar, process meat ( I dont eat them)'' what do you think? and he said to eat more celeri, celeri rave, cucomber, water, yellow apples, noix de grenobles, so wy would I have cristals if I dont eat frustose or sugar, I eat meat, keto veggies, keto fruits good fats and he also said that I still have low llymphocyte so he prescribed supplements thymus and manganese cobat for my anxiety, pvc, tremors and digestion, I add it in januray also from blood test, he checked my cholesterol and sugar all is good, thanks if you can help xox I cut all sugars 18 mounts ago
    Reply: #61
  11. Kristin Parker Team Diet Doctor
    Fruits, even keto friendly still have sugars.
  12. Constantina
    I had my first gout attack in October of 2018 after being keto for 18 months and low carb for two years (reversed diabetes and fatty liver, lost 50 pounds but want to lose 30-40 more. Also have lost a lot of muscle and slowed my metabolism, which is concerning). It resolved with the indomethacin my doctor gave me, but I did not want to keep taking that. When I had another attack a couple of months later, I bought some tart cherry capsules and it reversed even faster. A little bit of research revealed that better hydration and b vitamins can help. I haven’t read all the comments here, but I did see one that suggests gout is related to sleep apnea. I have a sleep study scheduled next month.
  13. Donna M Payne
    I am 57 yrs old and I am doing great on the Keto diet but after I drank some electrolytes I got a mild case of gout. I have never had gout before. It is not super painful but it is there. I am just starting my 2nd week on Keto and I am doing intermittent fasting because I am not hungry and I am drinking lots of water and adding salt to my diet when I eat. I have fasted about 18 hours on Thursday and I will be doing 18 hours today (Saturday). I am already down from 140 to 133 lbs. I feel great and I have more energy than I have had in a long time. I also have very little appetite. I eat maybe once a day or sometimes twice. I wanted to give you some back ground on what I have been doing.
    Once you have gout how long before it goes away?
    Reply: #64
  14. Kristin Parker Team Diet Doctor
    Donna, this is from the article and may help answer your question.
    "However, there may possibly be a temporary increase in risk of gout during the first six weeks on a strict low-carb diet. After this initial time period, a low-carb diet is likely neutral, or even protective, when it comes to gout."
  15. Michael
    I had not had a gout attack in literally years until, six weeks into the keto diet, just recently I developed bad gout in my right foot.

    I feel that advocates of the diet may be in denial about this side-effect – it is simply not correct to say that the keto diet does not cause gout – there is certainly nothing imaginary about the excruciating pain!

    That is not to say that, overall, I am critical of the diet – far from it – I have already lost 7 kg and very much want to continue on it but unless I can get the gout under control it will be impossible – the pain is simply too bad.

    My doctor warned me that Allopurinol can actually exacerbate the problem in the short term so I was interested to read, earlier in this thread, of another drug without this affect .

    I’ve also been told that drinking a ridiculous amount of water plus adding some vitamin C can help to flush out the kidneys and correct gout.

    Any other thoughts or observations would be most welcome.

    Michael

1 2

Leave a reply

Reply to comment #0 by